Forefoot

Issues

 

1.  Painful Bunion / Hallux valgus

 

Rheumatoid Forefoot Hallux Valgus

 

2.  Metatarsalgia / MTPJ dislocation

 

Rheumatoid Foot

 

3.  Claw toes

 

Claw Toes

 

Pathology

 

Earliest manifestation is synovitis of MTPJ 

- capsular destruction 

 

Dorsal subluxation MTPJ

- claw toes develop (MTPJ hyperextended, PIPJ flexed)

 

Plantar fat pad displaced distally

- MT heads exposed to plantar skin

- corns develop over PIPJ & under MT heads

 

Management

 

Non-operative Management

 

Shoe-wear modification

 

Extra-depth shoe / low heel / roomy toe-box

Custom-made arch support

Pre-MT dome for metatarsalgia

Heel cup to prevent heel valgus

STJ - single lateral upright with medial T strap

AKJ - double upright with square ferrule

 

Operative Management

 

Indications

 

Continuing pain

Increasing deformity

Footwear modification failure

 

Issues

 

Poor wound healing

Infection

Non-union

Recurrence of deformity

 

Timing in multiple joint surgery

 

Forefoot often first

- eliminates pedal sepsis

 

Hallux Valgus / Rigidus

 

Options

- arthrodesis

- arthroplasty

- Keller's procedure

 

Arthrodesis

 

Rheumatoid Forefoot Fowlers MTPJ Fusion

 

Procedure of choice

- provides forefoot power & buttresses lesser toes

 

Contra-indication

- involvement of IPJ 

- need to have mobile IPJ to put tip of toe onto the ground

- consider arthroplasty

 

Complication

- non-union

- malposition

- stress transfer to IPJ

 

Silicone Arthroplasty / Double-Stemmed Swanson

 

Indication

- low-demand patient

- IPJ of hallux affected

 

Complication 

- breakage

- silicone synovitis

 

Keller's Procedure

 

Indication

- in low demand patient where bony union expected to be difficult

- salvage procedure

 

Complication

- cock up deformity

- transfer metatarsalgia

- loss of power

- recurrence

 

Metarsalgia

 

Options

- synovectomy

- Weil's osteotomy

- Fowler's procedure

 

Synovectomy

 

Indication

- early disease / synovitis

 

Technique

- 3 incision

- one over first MT

- 2 between 2/3 and 4/5

- incise extensor hood

 

Weil's Osteotomy

 

Indications

- enlocated MTPJ

- i.e. in conjuction with treatment of claw toe

 

Technique

- transverse osteotomy

- MT head moved proximally

- secured with screw

 

Fowler's operation 

 

Fowlers

 

Indication

- dislocation MTPJ

 

Concept

- cascading excision of II - V MT heads 

- 2nd 3 mm longer than 1st or 3rd

- 3rd 3mm longer than 4th

- 4th 3 mm longer than 5th 

 

Technique

 

Single dorsal transverse skin excision just proximal to toe webs 

- can be performed via transverse plantar ellipse

- with severe dislocation may be easier to approach through plantar aspect 

- MT heads subcutaneous & NV bundle usually subluxed dorsally

 

Extensor tenotomy

 

MT heads excised in gentle curve

- dorsal distal to plantar proximal

- contoured on plantar surface to give rounded surface

- very little length removed from 5th MT 

- must not leave bony fragments in weight bearing pad

 

Second incision on plantar surface 

- proximal to MT heads

- ellipse of skin only excised 

- closed to pull skin of forefoot under MT ends

 

Claw toes

 

EPL lengthening / EDB tenotomy / PIPJ fusion